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psnet.ahrq.gov/node/60167/psn-pdf
April 12, 2024 - Discharge Planning and Transitions of Care
March 25, 2020
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
Background
Transitions of care refer to the movement of patients between different healthcare se…
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/resuscitate-or-not
November 01, 2011 - To Resuscitate or Not?
Citation Text:
Wu AW, Pronovost P. To Resuscitate or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/web-mm/which-end-which
February 09, 2011 - Which End Is Which?
Citation Text:
Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 24, 2024
Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/zero…
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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia
May 1, 2006
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia.
PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
Perspective
Over the last decade, sur…
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psnet.ahrq.gov/node/836941/psn-pdf
April 27, 2022 - Overview of Home-Based Primary Care: Learning from the Field,”
identifies salient points and lessons learned
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - However, we all know that healthcare requires data which is timely and interoperable; we certainly learned … establishing the systems of safety and those key tools of high-reliability organizations that we have learned
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - However, we all know that healthcare requires data which is timely and interoperable; we certainly learned … establishing the systems of safety and those key tools of high-reliability organizations that we have learned
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - December 14, 2022
Lessons learned in implementing a chronic opioid therapy management
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Surgery
February 28, 2024
Understanding ultrarare adverse events - lessons learned
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - As the nurse recalled, “I learned a serious
lesson, which I certainly had been taught in nursing school
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psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - SPOTLIGHT CASE
Robotic Surgery: Risks vs. Rewards
Citation Text:
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - Ideally, the hospital would have learned from the first AMA departure as a sentinel event and would be
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - And they have learned from this.
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - departments, complex patients just disappear in
the ICU or disappear into the morgue and you haven't really learned
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psnet.ahrq.gov/node/33814/psn-pdf
September 01, 2016 - We've learned that
physicians who have a lot of experience with particular health interventions usually
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psnet.ahrq.gov/issue/safety-you-go-hospital-home
November 23, 2016 - Fact Sheet/FAQs
Safety as You Go from Hospital to Home.
Citation Text:
Safety as You Go from Hospital to Home. National Patient Safety Foundation; NPSF
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psnet.ahrq.gov/issue/medical-culture-about-errors-may-be-changing
September 19, 2018 - Newspaper/Magazine Article
Medical culture about errors may be changing.
Citation Text:
Medical culture about errors may be changing. Gulliver D. Herald Tribune. September 3, 2007.
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